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Your Source for updates to Medicare-covered services

The Centers for Medicare & Medicaid Services (CMS) makes changes to the services that are covered by Medicare. These changes are updated via National Coverage Determinations. CMS has issued the following National Coverage Determinations:

Effective 9/27/13: Beta Amyloid Positron Emission Tomography (PET) in Dementia and Neurodegenerative Disease

The Centers for Medicare & Medicaid Services (CMS) will only allow coverage with evidence development (CED) for Positron Emission Tomography (PET) beta amyloid imaging (also referred to as amyloid-beta (Aβ)) when specific conditions are met. In accordance with CMS guidance, Humana will allow for this service when the specified criteria are met.

Effective 8/13/13: Single Chamber and Dual Chamber Permanent Cardiac Pacemakers

The Centers for Medicare & Medicaid Services (CMS) concluded that implanted permanent cardiac pacemakers, single chamber or dual chamber, are reasonable and necessary for the treatment of non-reversible symptomatic bradycardia due to sinus node dysfunction and second and/or third degree atrioventricular block. In accordance with CMS guidance, Humana will allow for this service when the specified conditions are met.

Effective 6/11/13: Fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) for Solid Tumors

The Centers for Medicare & Medicaid Services (CMS) has ended the Coverage with Evidence Development (CED) requirement for FDG PET and PET/CT and PET/MRI for all oncologic indications. In accordance with CMS guidance, Humana will allow for this service without the CED requirement.

Effective 5/29/13: Aprepitant for Chemotherapy Induced Emesis

The Centers for Medicare & Medicaid Services (CMS) has included additional anti-cancer chemotherapeutic agents to the list of agents for which the use of the oral antiemetic 3-drug combination of oral aprepitant, an oral 5HT3 antagonist and oral dexamethasone is deemed reasonable and necessary. In accordance with CMS guidance, Humana will allow for these additional agents.

Effective 4/2/13: Ocular Photodynamic Therapy with Verteporfin for Macular Degeneration

The Centers for Medicare & Medicaid Services (CMS) will expand coverage of Ocular Photodynamic Therapy with verteporfin for “wet” age-related macular edema. CMS is revising the requirements for testing to permit either optical coherence tomography or fluorescein angiography to assess treatment response. In accordance with CMS guidance, Humana will allow for this service when the specified criteria are met.

Effective 3/7/13: Positron Emission Tomography (PET) Scans

The Centers for Medicare & Medicaid Services (CMS) will allow local Medicare Administrative Contractors (MACs) to determine coverage within their respective jurisdictions for positron emission tomography (PET) using radiopharmaceuticals for their Food and Drug Administration (FDA) approved labeled indications for oncologic imaging. In accordance with CMS guidance, Humana will follow these determinations.

Effective 8/2/12: Autologous Platelet-Rich Plasma (PRP) for Chronic Non-Healing Wounds

The Centers for Medicare & Medicaid Services (CMS) will allow coverage for autologous platelet-rich plasma (PRP) only for the treatment of chronic non-healing diabetic, venous and/or pressure wounds when PRP is provided under a clinical research study that meets specific requirements. In accordance with CMS guidance, Humana will allow for this service when the specified criteria are met.

Effective 6/27/12: Bariatric Surgery for Treatment of Morbid Obesity

The Centers for Medicare & Medicaid Services (CMS) will allow coverage of stand-alone Laparoscopic Sleeve Gastrectomy (LSG) for the treatment of co-morbid conditions related to obesity in Medicare beneficiaries when specific conditions are met. In accordance with CMS guidance, Humana will allow for this service when the specified criteria are met.

Effective 6/8/12: Transcutaneous Electrical Nerve Stimulation (TENS) for Chronic Low Back Pain (CLBP)

The Centers for Medicare & Medicaid Services (CMS) will allow coverage for Transcutaneous Electrical Nerve Stimulation (TENS) for Chronic Low Back Pain (CLBP) only when the patient is enrolled in an approved clinical study under Coverage with Evidence Development (CED). Claims should be submitted and reimbursed by the Medicare Administrative Contractor.

Effective 5/1/12: Transcatheter Aortic Valve Replacement (TAVR)

Transcatheter Aortic Valve Replacement (TAVR) is covered for the treatment of symptomatic aortic valve stenosis when furnished according to a Food and Drug Administration (FDA)-approved indication and when various conditions outlined in the National Coverage Determination (NCD) are met. For indications that are not approved by the FDA, patients must be enrolled in qualifying clinical studies that meet requirements. In accordance with CMS guidance, Humana will allow for this service when the specified criteria are met.

Effective 6/21/12: Liver Transplants

Medicare Administrative Contractors acting within their respective jurisdictions may determine coverage of adult liver transplantation for the following malignancies: (1) extrahepatic unresectable cholangiocarcinoma (CCA); (2) liver metastases due to a neuroendocrine tumor (NET); and, (3) hemangioendothelioma (HAE). In accordance with CMS guidance, Humana will follow the directions of any issued determinations.

Effective 5/1/08: Heart Transplants

Cardiac transplantation is covered under Medicare when performed in a facility which is approved by Medicare as meeting institutional coverage criteria. In accordance with CMS guidance, Humana will allow for this service under the specified criteria.

 

Effective 4/30/12: Extracorporeal Photopheresis

CMS will cover extracorporeal photopheresis for the treatment of Bronchiolitis Obliterans Syndrome (BOS) following lung allograft transplantation only when extracorporeal photopheresis is provided under a clinical research study that meets specific requirements to assess the effect of extracorporeal photopheresis for the treatment of BOS following lung allograft transplantation. In accordance with CMS guidance, Humana will now allow for this service under the specified conditions.

 

Effective 11/29/11: Obesity Therapy

CMS has determined that screening for obesity in older adults along with high intensity behavioral interventions is reasonable and necessary for the prevention or early detection of illness or disability. In accordance with CMS guidance, Humana will now allow for these preventive services.

 

Effective 6/30/2011: Autologous Cellular Immunotherapy Treatment for Prostate Cancer

CMS has determined that the use of PROVENGE® for the treatment of asymptomatic or minimally symptomatic metastatic castrate-resistant (hormone refractory) prostate cancer is reasonable and necessary. In accordance with CMS guidance, Humana will now allow the use of PROVENGE® for Medicare Advantage patients with these diagnoses.

 

Effective 7/7/2011: Magnetic Resonance Imaging (MRI)

CMS has determined that the evidence is adequate to conclude that magnetic resonance imaging (MRI) improves health outcomes for Medicare beneficiaries with implanted permanent pacemakers (PMs) when the PMs are used according to the FDA-approved labeling for use in an MRI environment. In accordance with CMS guidance, Humana will now allow the use of MRIs for Medicare Advantage patients with permanent pacemakers.

 

Effective 10/14/2011: Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse

CMS will now cover an annual alcohol misuse screening and up to four, brief face-to-face behavioral counseling visits in a primary care setting to reduce alcohol misuse. In accordance with CMS guidance, Humana will now allow for these preventive services.

 

Effective 10/14/2011: Screening for Depression in Adults

CMS will now cover an annual screening up to 15 minutes for Medicare beneficiaries when staff-assisted depression care supports are in place to assure accurate diagnosis, effective treatment, and follow-up. In accordance with CMS guidance, Humana will now allow a screening as a preventive service.

 

Effective 11/8/2011: Intensive Behavioral Therapy for Cardiovascular Disease

CMS now covers intensive behavioral therapy for cardiovascular disease, inclusive of one face-to-face risk reduction visit annually. In accordance with CMS guidance, Humana will now allow for this preventive service.

 

Effective 11/8/2011: Screening for Sexually Transmitted Infections (STIs) &High Intensity Behavioral Counseling to Prevent STIs

The evidence is adequate to conclude that screening for chlamydia, gonorrhea, syphilis and hepatitis B, as well as high intensity behavioral counseling (HIBC) to prevent STIs is reasonable and necessary for the prevention or early detection of an illness or disability. Therefore, CMS will cover screening for these indicated STIs with the appropriate laboratory tests when ordered by the primary care physician or practitioner. In accordance with CMS guidance, Humana will now allow for these preventive services.

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